Scenario: A group of dedicated psychologists and lobbyists draft a comprehensive mental health parity bill for their state. The legislation gains support from an influential senator and is introduced to the state legislature. A public hearing is held--complete with expert testimony from esteemed psychologists and consumers on the need for parity. The Senate passes the bill, and it goes to the House for a vote, where it meets with enthusiastic support from psychology-friendly representatives and passes to thunderous applause.
Isn't that the way it works? Well, not really. The old adage "Nothing is easy" well describes the course of state legislation.
"The whole legislative process is like one of your kids," says Dan Abrahamson, PhD, director of professional affairs for the Connecticut Psychological Association. "You don't really notice how much they're growing. But if you've kept their measurements, you can really see what's happened."
Lorryn Wahler, executive director for the New Jersey Psychological Association (NJPA), gives a no-frills perspective on the often-lengthy course of state legislation: "It's a brutal process," she declares. After working at NJPA for 17 years, she understands that advocacy work takes time. "And the ability to compromise," she adds.
Indeed, law-making is often a tedious process. Licensure of psychologists took 30 years to pass in all 50 states; while Connecticut began licensing in 1945, Missouri passed its licensure law in 1979. When it comes to broad-based mental health parity, only 13 states have laws in place. Similarly, affirming independent hospital practice for psychologists took 20 years to pass in 18 states. In California, a bill was introduced in 1975, passed in 1978, challenged in 1982 and finally upheld in 1990 by the California Supreme Court.
Sluggish, yes, admit psychology's state advocates. But that give-and-take, as long-winded as it can be, is exactly what our forefathers envisioned two centuries ago.
"Legislative advocacy is a process, not an event," says Russ Newman, APA's executive director for practice.
"It's messy," adds Michael Sullivan, PhD, APA's assistant executive director for state advocacy, "but it's democracy."
In it for the long haul
Abrahamson tells his own war story about the five years of intense work it took to achieve mental health parity in Connecticut. "In 1995, a coalition of mental health groups went to the legislature and advocated for parity, and we got nowhere," he remembers. "We weren't even a blip on the radar screen."
In 1996, they went back again, armed with actuarial data on the benefits of parity. They secured a public hearing, but the momentum ended there until the 1996 passage of the federal Mental Health Parity Act, sponsored by Sens. Pete Domenici (R-N.M.) and Paul Wellstone (D-Minn.)--which bolstered their efforts on the state level.
"We were stronger," says Abrahamson. "We had laid the groundwork. The legislators already knew about the issue and now we had the federal precedent to build on."
Even so, the coalition had to compromise, ending up with coverage for only 11 diagnoses. "We had a partial victory," says Abrahamson. "But we weren't ready to give up."
In 1998, the group collected data to support amending the law to include full coverage. 1999 offered them a golden opportunity: "We got an influential partner in the senate and we got the support of the public health committee for another public hearing," he says. "It passed, finally."
Implementation took another year or so. "Now--six or seven years from the start of our initiative--things are finally working properly," he says.
Appreciating the little things
Sally Cameron, executive director for the North Carolina Psychological Association (NCPA), says she's learned to appreciate incremental successes on the legislative front.
After 20 years of advocacy work, she says the key is "to be in the frame of mind that you're pursuing an end goal--and sometimes you have to settle for part of the goal."
Today, Cameron is working to expand a North Carolina budget provision that would reimburse psychologists under Medicaid for services to children. Her goal is to get the same reimbursement for adults.
"We've been chipping away at this issue for four or five years," she says, "and we're only halfway there."
Another example of incremental success: In New Mexico, a prescription privileges bill nearly passed this year but was stalled in the Senate just as the legislative session ended. Regardless, the bill gained enormous support and the New Mexico Psychological Association plans to keep up the momentum in future sessions.
Jim Quillin, PhD, has worked on prescription privileges in Louisiana since 1992. In 1996, they introduced the first bill.
"It passed through the House Health and Welfare Committee with only one vote against it," he says. But then, the small group of advocates "didn't have the leg to push it further that year."
In 1998, they introduced another bill. This time, they managed to keep it alive in both the House and the Senate Health and Welfare Committees but, Quillin says, the clock ran out on them. Again in 2000, the bill sailed through committee in the Senate but failed in the House.
"We'll pass the bill. When is what we don't know," says Quillin. "This is a process. You only lose if you quit."
Strategies for success
For many associations, having an expert to track issues and strategize has been a key component of moving advocacy efforts along as quickly as possible. Even in states like New Jersey and North Carolina, where Wahler and Cameron are both registered lobbyists, the associations have hired outside help.
"Psychology is no longer a mom-and-pop profession," says Wahler. "If you look at states that are successful, they have a good volunteer and staff arrangement."
To support state associations' efforts to beef up their advocacy, APA's Committee for the Advancement of the Practice of Psychology has given states grants to hire staff and retain lobbying services. Goal No. 1 for the lobbyists, paid association staff and members who work together is building relationships with legislators--an endpoint they achieve in a variety of ways. NJPA hosts casual dinners. "These are informal meetings, not issues-oriented," says Wahler. "When legislators meet psychologists, switching to more intimate settings gives us an advantage."
Cameron says she and volunteers in North Carolina dedicate a great deal of time educating legislators on psychological issues. They create fact sheets and when needed hand-deliver the information. NCPA also sponsors "lobby days" along with a large coalition of mental health-related groups.
"The legislators really look to the professionals for accurate facts--not just a position," she says.
Other state psychological associations hold "legislative days" where members meet for training on issues and talking points and then visit their legislators--the state-level version of APA's State Leadership Conference Capitol Hill visits.
"Legislators need to know you and if they have a good impression, they'll remember your issues," says Abrahamson. "As psychologists, some of that should come naturally to us--establishing relationships and understanding their value."
"You just don't build the relationships and stop," adds Robbie Thomas-Knight, director of professional affairs for the Arkansas Psychological Association. "It's an ongoing process and a continuing responsibility."